Tacks, staples, or suture: method of peritoneal closure in laparoscopic transabdominal preperitoneal inguinal hernia repair effects early quality of life

Comparing stapler and sutured mesh fixation techniques for laparoscopic TAPP repair: a study on chronic groin pain on 3-year follow-up

Trans-abdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repairs are the available surgeries for inguinal hernias, with both methods of laparoscopic repairs requiring mesh applications. This study analyzes the correlation between sutured versus stapler mesh fixation in a laparoscopic TAPP for unilateral groin hernia regarding chronic pain during 3-year follow-up. A total of 130 patients with laparoscopic hernia undergoing TAPP repair were randomized into 2 groups based on their fixation technique-one with sutures and the other with stapler. Postoperative complications and chronic groin pain were noted for each technique. Equal number of participants was present in the stapler and suture groups, with the majority having an ASA score of one. The mean age was 42.50 ± 13.86 years, and the body mass index (BMI) was 27.47 ± 5.88. The stapler group presented a shorter mean operative time than the suture group. However, the stapler group had a significantly higher mean VAS score than the suture group. Most participants in the suture group (89.2%) had LOS for 1 day, while a 2-day LOS was significantly higher in the stapler group (12.3%) than in the suture group (9.2%). No patient reported mesh erosion, conversion, recurrence, testicular atrophy, and mesh infection. Early postoperative pain was more in stapler group along with long hospital stay, but both were non-significant. Chronic postoperative pain results and recurrence incidences over 3-year follow-up were also similar. Re-admission rates were minimal, no significant complications occurred.

Trends and predictors of laparoscopic bilateral inguinal hernia repair in Spain: a population-based study

BACKGROUND

International guidelines currently recommend laparoscopy for bilateral inguinal hernia repair (BIHR). Our study aims to evaluate the trends and factors associated with the choice of laparoscopy for BIHR in Spain.

METHODS

We performed a retrospective analysis of patients undergoing BIHR between 2016 and 2019. We used the national database of the Spanish Ministry of Health: RAE-CMBD. We performed a univariate and multivariable logistic regression analysis to identify the factors associated with the utilization of laparoscopy. We identified perioperative complications and the factors associated with their occurrence through multivariable logistic regression analysis.

RESULTS

A total of 21,795 BIHRs were performed: 84% by open approach and 16% by laparoscopic approach. Laparoscopic approach increased from 12% in 2016 to 23% in 2019 (p < 0.001). The 40% of hospitals did not use laparoscopy, and only 8% of the hospitals performed more than 50% of their BIHRs by laparoscopy. The utilization rate of laparoscopy was not related to the number of BIHRs performed per year (p = 0.145). The main factor associated with the choice of laparoscopy in multivariable logistic regression analysis was the patient's region of residence (OR 2.04, 95% CI 1.88-2.21). Other factors were age < 65 years (OR 1.65, 95% CI 1.52-1.79) and recurrent inguinal hernia (OR 1.31, 95% CI 1.15-1.49). The type of approach for BIHR was not independently associated with perioperative complications.

CONCLUSIONS

Despite a significant increase in recent years, laparoscopic BIHR in Spain remains low. The main factor associated with the utilization of laparoscopy was the patient's region of residence; this factor seems to be related to the presence of hospitals with a high rate of laparoscopic approaches where the patient lives. The type of approach was not independently associated with perioperative complications. More efforts are needed to increase laparoscopic use in patients with bilateral inguinal hernias.

Mesh Migration and Bowel Perforation as a Late Complication of Transabdominal Preperitoneal Laparoscopic Hernia Repair

Minimally invasive surgery is increasingly used in the treatment of inguinal hernias, with two main techniques described: transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP). In both techniques, a prosthetic mesh is placed in a preperitoneal position. However, in TAPP, the peritoneum flap must be completely closed. The TAPP technique is associated with more intra-abdominal complications. This article describes a case of bowel occlusion due to migration and erosion of a mesh after a TAPP repair in a 57-year-old patient with a history of colonic diverticular disease. The patient complained of abdominal discomfort and constipation, having undergone a colonoscopy and CT scan that demonstrated the presence of a foreign body partially in the lumen of the sigmoid colon. The treatment was surgical, with bowel resection and partial removal of the mesh, complicated by a deep tissue collection. The patient maintained follow-up in a surgery consultation, with no evidence of hernia recurrence. This is a rare complication of the laparoscopic approach in the treatment of inguinal hernia, more frequent in the TAPP technique. It is intended to draw attention to the type of closure of the peritoneum.

[Pain and quality of life after laparoscopic transabdominal preperitoneal hernioplasty with different ways of fixing the peritoneum. Results of early completion randomized clinical trial]

OBJECTIVE

To compare and statistically evaluate the severity of pain syndrome and quality of life depending on the method of fixation of the parietal peritoneum during laparoscopic hernia repair (suture fixation or the use of tack fixation).

METHODS

A randomized clinical trial was conducted from May to June 2021 at the Lomonosov Moscow State University Medical Center. It was planned to observe patients for a year. In the first group, the fixation of the parietal peritoneum was performed using suture fixation, in the second group, the peritoneal flap was fixed using a fixation device. In the course of statistical data processing, it was planned to study the dependence of the duration of the operation, the severity of the pain syndrome in the early postoperative period, the frequency of complications, the quality of life of patients in the postoperative period on the chosen method of the fixation of the parietal peritoneum.

RESULTS

At the initial stage of the study, 8 patients with inguinal hernias were selected in the first group during randomization, and 6 patients were selected in the second group. Each patient of the second group in the early postoperative period had a more pronounced local pain, protective muscle tension in the projection of fixation of the parietal peritoneum with tacks, which was accompanied by negative psychoemotional reactions, an increase in the dose of analgesic drugs. Due to the revealed features of the early postoperative period in patients of second group, it was considered unethical and inappropriate to continue the study within the protocol.

CONCLUSION

The results obtained do not allow us to draw statistically supported conclusions. The solution of the problem of the peritoneal flap fixation method is possible in two ways: abandoning stapler fixation in favor of suture or conducting additional clinical studies with an analysis of the impact of the choice of peritoneal fixation technique not only on acute and chronic postoperative pain, but on quality of life in the early and delayed postoperative periods.

Non-closure of the Free Peritoneal Flap During Laparoscopic Hernia Repair of Lower Abdominal Marginal Hernia: A Retrospective Analysis

Background: During lower abdominal marginal hernia repair, the peritoneal flap is routinely freed to facilitate mesh placement and closed to conclude the procedure. This procedure is generally called trans-abdominal partial extra-peritoneal (TAPE). However, the necessity of closing the free peritoneal flap is still controversial. This study aimed to investigate the safety and feasibility of leaving the free peritoneal flap in-situ. Methods: A retrospective review was conducted on 68 patients (16 male, 52 female) who underwent laparoscopic hernia repair between June 2014 and March 2021. Patients were diagnosed as the lower abdominal hernia and all required freeing the peritoneal flap during the operation. Patients were divided into 2 groups: one group was TAPE group with the closed free peritoneal flap, another group left the free peritoneal flap unclosed. Analyses were performed to compare both intraoperative parameters and postoperative complications. Results: There were no significant differences in demographic, comorbidity, hernia characteristics and ASA classification. The intra-operative bleeding volume, visceral injury, hospital stay, urinary retention, visual analog scale (VAS) score, dysuria, intestinal obstruction, surgical site infection, mesh infection, recurrence rate and hospital stay were similar among the two groups. Mean operative time of the flap closing procedure was higher than for patients with the free peritoneal flap left in-situ (p = 0.002). Comparisons of postoperative complications showed flap closure resulted in a higher incidence of seroma formation (p = 0.005). Conclusion: Providing a barrier-coated mesh is used during laparoscopic lower abdominal marginal hernia repair, it is safe to leave the free peritoneal flap in-situ and this approach may prevent the occurrence of seromas.

Comparison of Common Postoperative Complications Between Lichtenstein Open Repair and Laparoscopic Transabdominal Pre-peritoneal (TAPP) Repair for Unilateral Inguinal Hernia

Introduction

Laparoscopic transabdominal pre-peritoneal (TAPP) repair is a minimally invasive technique that is becoming the procedure of choice among surgeons for inguinal hernia repair and research work is still going on comparing TAPP repair with Lichtenstein open mesh repair. The objective of our study is to compare common postoperative complications in Lichtenstein mesh repair and laparoscopic TAPP repair for unilateral inguinal hernia in our unit.

Methods

Between August 2016 and August 2018, patients with unilateral inguinal hernia and ASA grade I/II were selected in the surgical outpatient department (OPD) and prospectively randomized into two equal groups. Lichtenstein open mesh repair was done in Group-I and laparoscopic TAPP repair in Group-II. The visual analog scale (VAS) was used for the assessment of the intensity of pain.

Results

A total of 100 patients with a diagnosis of unilateral inguinal hernia were included in the study. Overall, our study showed that there was less postoperative pain in those patients who underwent TAPP repair as compared to patients with Lichtenstein mesh repair (p= <0.05). There were more postoperative complications in Group-I as compared to Group-II.

Conclusion

Laparoscopic TAPP repair for inguinal hernia is associated with less postoperative pain and other postoperative complications in addition to a shorter hospital stay as compared to Lichtenstein mesh repair. Thus, this is helping in the early return of patients to daily life activities.

Recurrent abdominal pain due to small bowel volvulus after transabdominal preperitoneal hernioplasty: A case report and review of literature

BACKGROUND

Compared with open mesh repair, transabdominal preperitoneal (TAPP) hernioplasty results in less chronic postoperative inguinal pain and faster postoperative recovery. However, it may still lead to rare but serious complications. Here we report a case of intestinal volvulus with recurrent abdominal pain as the only clinical symptom, which occurred 3 mo after TAPP repair for bilateral inguinal hernia.

CASE SUMMARY

A 50-year-old male patient underwent laparoscopic TAPP for bilateral inguinal hernias. After the operation, he experienced recurring pain in his lower right abdomen around the surgical area, which was relieved after symptomatic treatment. Three months after the surgery, the abdominal pain became severe and was aggravated over time. The whirlpool sign of the mesentery was seen on contrast-enhanced computed tomography (CT). Laparoscopic exploration confirmed that a barb of the V-Loc™ suture penetrated the peritoneum, which caused the adhesion of the small intestinal wall to the site of peritoneal injury, forming intestinal volvulus. Since there was no closed-loop obstruction or intestinal ischemia, recurrent abdominal pain became the only clinical manifestation in this case. After laparoscopic lysis of adhesions and reduction of intestinal volvulus, the patient recovered and was discharged.

CONCLUSION

The possibility of intestinal volvulus should be considered in patients who experience recurrent abdominal pain following TAPP surgery during which barbed V-Loc sutures are used for closing the peritoneum. Contrast-enhanced CT and active laparoscopic exploration can confirm the diagnosis and prevent serious complications.

Preperitoneal herniation as a complication of tansabdominal preperitoneal patch plasty: a report of two cases

BACKGROUND

Preperitoneal herniation is a rare complication after transabdominal preperitoneal patch plasty (TAPP) and may be caused by inadequate peritoneal closure. We herein report two cases of postoperative small bowel obstruction due to preperitoneal herniation through a disrupted peritoneum.

CASE PRESENTATION

Two men in their 70s were admitted to our center because of small bowel obstruction after TAPP. After examinations and unsuccessful conservative treatment, emergency laparoscopic exploration was performed. Preperitoneal herniation through the disrupted peritoneum was found. The herniated small bowel was reduced and the peritoneum was properly reclosed. The patients recovered and were discharged with normal bowel function.

CONCLUSIONS

Inadequate peritoneal closure may cause preperitoneal herniation and lead to postoperative small bowel obstruction and even death. Hernia surgeons can avoid this complication by improving their suture technique and paying attention to the procedure details.

Initial experience using a handheld fully articulating software-driven laparoscopic needle driver in TAPP inguinal hernia repair

Background

The laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is a widely performed minimally invasive operation, but can present considerable ergonomic challenges for the surgeon. Our objective was to determine if a novel handheld software-driven laparoscopic articulating needle driver can mitigate these difficulties.

Methods

The video recordings of a consecutive series of TAPP cases by a single surgeon using the articulating device were compared with a series of cases using straight-stick laparoscopy. Two critical steps of the procedure were analyzed for time: mesh fixation and peritoneal suture closure. These steps were then compared before and after 10 initial consecutive cases to analyze whether the surgeon demonstrated improvement. A cost analysis was also performed between the two techniques.

Results

For mesh fixation, the surgeon averaged 227 s using tacker devices, compared with 462.4 s using the novel laparoscopic device (p = 0.06). For the peritoneal closure component of the operation, the surgeon improved the time per suture pass during closure from 60.61 s during the first 10 cases to 38.84 s after the first 10 cases (p = 0.0004), which was comparable to the time per stitch for standard laparoscopy (34.8 s vs 34.84 s, p = 0.997). Left-sided inguinal hernia repairs using the articulating device demonstrated a significantly longer time per stitch during peritoneal closure compared to the right side after first 10 cases (left: 40.62 s; right: 27.91, p = 0.005). Our direct cost analysis demonstrated that suture closure of the peritoneum using the articulating device was more cost-effective than tack fixation.

Conclusions

After only a 10 case initial experience, a laparoscopic hand-held articulating needle driver is comparable to standard laparoscopy to complete suture mesh fixation and peritoneal closure for TAPP inguinal hernia repair. Further, the feasibility of suture mesh fixation minimizes the need for costly tacker devices. This instrument appears to be a promising tool in this largely minimally invasive era of hernia repair.

A New Suture Technique for Peritoneal Flap Closure in TAPP: A Prospective Randomized Controlled Trial

PURPOSE

To facilitate the suture step, we describe a new suture method for laparoscopic closure of the peritoneal flap in transabdominal preperitoneal (TAPP). A prospective randomized controlled trial was carried out to evaluate the efficacy of the new suture method compared with the conventional method.

METHODS

Eighty patients who presented to our hospital in May 2019 with primary unilateral inguinal hernia were randomized into the conventional suture method group and the new suture group for TAPP repairs. The primary outcome was the suture time to complete the peritoneal flap closure. Secondary outcomes included the number of cases of peritoneum tearing, need for additional suture, and suture line breaking.

RESULTS

The suture time in the new suture method group was significantly shorter than that of the conventional group (715.3±132.4 s vs. 840.71±137.9 s, P<0.001); furthermore, there were significantly less number of cases of peritoneal tearing in the new suture method group than in the conventional suture method group (4 vs. 11, P<0.01).

CONCLUSIONS

The new suture method is relatively easy to learn for beginners performing TAPP procedures, as compared with the conventional method, and less peritoneal tearing is encountered when using this method for peritoneal flap closure.

Changing the innate consensus about mesh fixation in trans-abdominal preperitoneal laparoscopic inguinal hernioplasty in adults: Short and long term outcome. Randomized controlled clinical trial

INTRODUCTION

Inguinal hernioplasty is the standard treatment for inguinal hernia in adults. Mesh fixation was used to keep mesh in place for which various mesh fixation techniques have been used in laparoscopic inguinal hernia repair in adults, but their effectiveness has remained inconclusive.

AIM OF THE WORK

to evaluate non fixation method of mesh laparoscopic inguinal hernioplasty as safe and effective as regard short and long term outcomes.

PATIENTS AND METHODS

Over the period from July 2013 to July 2018, 798 patients with oblique inguinal hernias undergoing Trans abdominal preperitoneal technique (TAPP) were randomized into 3 groups: Group A; mesh non fixation 266 patients. Group B; tacker mesh fixation 266 patients Group C: Cyanoacrylic tissue glues (Histoacryl) mesh fixation 266 patients. Clinical effects were assessed by the following variables: intraoperative data, postoperative outcome as regard recurrence rate, postoperative pain [on visual analogue score (VAS)], analgesic consumption, operation time, hospital stay, and patient costs. Follow up was 18 months.

RESULTS

There was no statistical difference between groups (A) and Group (C) regarding operative time, postoperative complications, and length of hospital stay and risk of chronic groin pain, postoperative pain score. In Group (B): the postoperative pain and complications were higher. There were 5 cases of hernia recurrence in all groups, but no significant differences among the three groups.

CONCLUSION

Tacker Mesh fixation increased the risk of chronic groin pain. Pain score was higher with tacker mesh fixation. Laparoscopic TAPP inguinal hernia repair without tacker mesh fixation was safe and feasible with no significant increase in recurrence rates. Furthermore, mesh fixation with tacker procedure increased the risk of postoperative complications and patient costs. All ethical approval was given by our Faculty of Medicine medical ethical committee.

Adhesional small bowel obstruction related to stapling device from previous laparoscopic inguinal hernia repair

Small bowel obstruction (SBO) is common surgical presenting problem, accounting for roughly 15 000 laparotomies per year in the UK. However, SBO post laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is uncommon with an estimated incidence of 0.2%-0.5%. The common causes for SBO post-TAPP include inadequate closure, port-site herniation and adhesions. Here, we present a case of adhesional SBO related to stapling device from previous laparoscopic inguinal hernia repair and review alternative methods for mesh fixation. This case reports a rare but life-threatening complication from a commonly performed day case procedure and highlights importance of adequate surgical technique when inserting foreign bodies intra-abdominally. The patient required an emergency laparotomy and small bowel resection, developed postoperative ileus which managed with a nasogastric tube, intravenous fluids and parenteral nutrition and was discharged 12 days postoperatively.

Long-term assessment of surgical and quality-of-life outcomes between lightweight and standard (heavyweight) three-dimensional contoured mesh in laparoscopic inguinal hernia repair

BACKGROUND

Mesh weight is a possible contributor to quality-of-life outcomes after inguinal hernia repair. This study compares lightweight mesh versus heavyweight mesh in laparoscopic inguinal hernia repair.

METHODS

A prospective, single-center, hernia-specific database was queried for all adult laparoscopic inguinal hernia repair with three-dimensional contoured mesh (3-D Max, Bard, Inc, New Providence, NJ) from 1999 to June 2016. Demographics and outcomes were analyzed. Quality of life was evaluated preoperatively and after 2 weeks, 4 weeks, 6 months, 12 months, and 24 months, using the Carolinas Comfort Scale. Univariate analysis and multivariate logistic regression were performed.

RESULTS

A total of 1,424 laparoscopic inguinal hernia repair were performed with three-dimensional contoured mesh, with 804 patients receiving lightweight mesh and 620 receiving heavyweight mesh. Patients receiving lightweight mesh were somewhat younger (52.6 ± 14.8 years vs 56.3 ± 13.7 years, P < .0001), with slightly lower body mass indices (26.4 ± 9.9 vs 27.1 ± 4.3, P < .0001). Lightweight mesh was used less often in incarcerated hernias (12.5% vs 16.8%, P = .02). There were a total of 3 surgical site infections. There were no differences in complications between groups except for seroma. Although on univariate analysis, seromas appeared to occur more frequently with heavyweight mesh (21.5% vs 7.9%). On multivariate analysis, heavyweight mesh was not independently associated with seroma formation. Average follow-up was 20 months. Recurrence rates were similar between lightweight mesh and heavyweight mesh (0.7 vs 0.6% P > .05). At all points of follow-up (4 week to 3 years), quality-of-life outcomes of discomfort, mesh sensation, and movement limitation scores were similar between lightweight mesh and heavyweight mesh.

CONCLUSION

Contoured lightweight mesh and heavyweight mesh in laparoscopic inguinal hernia repair yield excellent recurrence rates and no difference in postoperative complications or quality of life. Considering the lack of outcome difference with long-term follow-up, heavyweight mesh may be considered for use in laparoscopic inguinal hernia repair patients.

Is there difference in chronic pain after Suture and Stapler fixation method of mesh in Ventral Hernia? Is stapler fixation method quicker? A randomized controlled trial

Background & Objective:

Chronic pain occurs in 20–30% of patients after hernia surgery. As a consequence of this chronic pain, almost one third of patients have limitations in daily activities. Frequency and severity of this pain varies with different techniques of hernia repair. The objective of this study was to compare polypropylene suture and skin staples for securing mesh in uncomplicated ventral hernioplasty in terms of acute and chronic postoperative pain and to compare the time taken for mesh fixation between polypropylene sutures and skin stapler in ventral hernioplasty.

Methods:

This study was conducted in Surgery Department of Dow University Hospital, Dow University of Health Sciences, Ojha Campus and included 53 patients from Jan 2015 to Dec 2016, after taking informed consent. All patients were operated under general anesthesia by the same surgical team. Patients were randomized into two groups; in one group mesh fixed with 2/0 polypropylene suture while in other group mesh stapler was used. Time taken to apply mesh was noted in minutes from laying the mesh over anterior rectus sheath to completion of fixation by either method. The severity of post-operative pain was measured with VAS (1-10) after one week, one month and after one year after surgery. Data was analysed using SPSS version 17.

Results:

Patient characteristics and operative outcome were similar in the two groups and statistically non-significant in both. Early postoperative pain was more after suture fixation but it was not statistically significant. Mean ± SD pain score was after one week 3.47±2.7 after sutures while 2.91±1.88 after stapler. After four weeks, 0.40±0.49 after suture while 0.35±0.48 after stapler fixation. In both study groups 30–34% of the patients felt some pain in follow-up after one year. Severity of pain was 0.60±0.62 after suture while 1.65±1.94 after stapler fixation which is statistically significant as well (p<0.007). Mean operative time was 15.33±6.33 minutes for suture fixation while 1.56±0.41 minutes for fixation by staples, p-value < 0.001.

Conclusion:

The method of fixation does not appear to cause significant difference in early post-operative pain but chronic pain is more after stapler fixation of mesh. However, operative time was reduced significantly in staple fixation group as compared to suture fixation group

Surgical training in robotic surgery: surgical experience of robotic-assisted transabdominal preperitoneal inguinal herniorrhaphy with and without resident participation

Robotic-assisted surgery is becoming more popular in general surgery. Implementation of a robotic curriculum is necessary and will influence surgical training. The aim of this study is to compare surgical experience and outcomes with and without resident participation in robotic inguinal herniorrhaphy. A retrospective review of patients who underwent either unilateral or bilateral robotic-assisted transabdominal preperitoneal (TAPP) inguinal herniorrhaphy, with and without resident participation as console surgeons from January through December 2015, was performed. Patient demographics, procedure-related data, postoperative variables, and follow-up data were analyzed. A total of 104 patients were included. Patients were significantly older in the Resident group (57.5 ± 14.1 vs 50.6 ± 13.5 years, p = 0.01). Gender, BMI, and ASA classification were similar between groups. There were similar mean operative times for unilateral (89.9 ± 19.5 vs 84.8 ± 22.2 min, p = 0.42) and bilateral (128.4 ± 21.9 vs 129.8 ± 50.9 min, p = 0.90) inguinal herniorrhaphy as well as mean robot console times for unilateral (73.2 ± 18.4 vs 67.3 ± 29.9 min, p = 0.44) and bilateral (115.5 ± 24.6 vs 109.3 ± 55.4 min, p = 0.67) inguinal herniorrhaphy with and without resident participation, respectively. Postoperative complications included urinary retention (11.1 vs 2.0%, p = 0.11), conversion to open repair (0 vs 2%, p = 0.48), and delayed reoperation (0 vs 4%, p = 0.22) with and without resident participation, respectively. Patients' symptoms/signs at follow-up were similar among groups. Robotic-assisted TAPP inguinal herniorrhaphy with resident participation as console surgeons did not affect the hospital operative experience or patient outcomes. This procedure can be implemented as part of the resident robotic curriculum with rates of morbidity equivalent to those of published studies.Level of evidence 2b.

Comparison of peritoneal closure versus non-closure in laparoscopic trans-abdominal preperitoneal inguinal hernia repair with coated mesh

BACKGROUND

Peritoneal closure during laparoscopic trans-abdominal preperitoneal (TAPP) inguinal hernia repair has been the standard of care to prevent bowel obstruction due to adhesions generated by contact with mesh. However, with newer coated meshes, leaving the peritoneal layer open may be safe. While many studies compare methods of peritoneal flap closure, there is a deficit of literature reporting the outcomes of non-closure.

METHODS

A retrospective comparison of peritoneal flap closure versus non-closure during primary laparoscopic TAPP inguinal hernia repair with coated mesh was performed for all patients at Baystate Medical Center meeting inclusion criteria between January 2005 and August 2016. Primary outcome was any procedure-related adverse outcome following repair. Secondary outcomes included operative time, resolution of pre-operative pain and/or gastrointestinal symptoms, and hernia recurrence.

RESULTS

Of 231 patients, 55 (24%) underwent peritoneal flap closure and 176 (76%) underwent non-closure. Demographic, comorbidity, and hernia characteristics were comparable between groups with the exception of obesity (p = 0.01), current smoking status (p = 0.05) and hernia side [p = 0.04 (left), 0.0003 (right)]. Mean operative time was higher in the closure group than non-closure (98.1 ± 37.1 min vs. 76.8 ± 32.9, p < 0.0001). No cases were converted to open. Average follow-up was 21.6 ± 23.8 months. Ninety-three percent of closure patients had documented resolution of pre-operative pain versus 94.0% of non-closure (p = 0.81). The closure group experienced a higher percentage of post-operative complications, though this did not reach significance (5.5 vs. 2.3%; p = 0.36). Compared to the closure group, the non-closure groups experienced similar post-operative pain (3.6 vs. 1.2%; p = 0.24) and recurrence rate (1.8 vs. 4.0%; p = 0.68). There were no bowel obstructions, surgical site infections, unplanned readmissions, or unplanned re-operations.

CONCLUSIONS

Equivalent patient outcomes were seen for both procedure types post-operatively and during follow-up. Operative times were significantly shorter for non-closure patients. Larger study population and longer follow-up is necessary to evaluate true long-term complication rates in flap non-closure.

A prospective randomized study comparing laparoscopic transabdominal preperitoneal (TAPP) versus Lichtenstein repair for bilateral inguinal hernias

BACKGROUND

In literature, only a few studies have prospectively compared the results of laparoscopic with open inguinal hernia repair yet none have compared bilateral inguinal hernia repair. The aim of this study is to compare the open Lichtenstein repair (OLR) with laparoscopic trans-abdominal preperitoneal (TAPP) repair in patients undergoing surgery for bilateral inguinal hernia.

METHODS

Patients were prospectively randomized between March 2013 and March 2015. Outcome parameters included hospital stay, operation time, postoperative complications, immediate postoperative pain and chronic pain, recurrence and quality of life.

RESULTS

Sixty-one patients underwent TAPP repair and 73 underwent OLR. TAPP procedure had less early post-operative pain up to 7 days from surgery (p = 0.003), a shorter length of hospital stay (p = 0.001), less postoperative complications (p = 0.012) and less chronic pain (0.04) when compared with the OLR approach.

CONCLUSIONS

TAPP procedure for bilateral inguinal hernia effectively reduces early postoperative pain, hospital stay and postoperative complications.

Does peritoneal flap closure technique following transabdominal preperitoneal (TAPP) inguinal hernia repair make a difference in postoperative pain? A long-term quality of life comparison

BACKGROUND

Transabdominal, preperitoneal (TAPP), laparoscopic inguinal hernia repair (IHR) requires the creation of a peritoneal flap (PF) that must be closed after mesh placement. Our previous study indicated that sutured PF closure resulted in less short-term postoperative pain at 2 and 4 weeks compared to tacks and staples. Therefore, the aim of this follow-up study was to compare short-term QOL with a greater sample size and long-term QOL at 2 years by method of PF closure.

MATERIALS AND METHODS

A prospective institutional hernia-specific database was assessed for all adult TAPP IHRs from July 2012 to May 2015. QOL outcomes were compared by PF closure method at 2 and 4 weeks and 6, 12, and 24 months as measured by the Carolinas Comfort Scale. Standard statistical tests were used for the whole population and then the Bonferroni Correction was used to compare groups (p < 0.0167). Multivariate analysis controlling for age, gender, recurrent hernias, and preoperative symptomatic pain was used to compare QOL by PF closure method.

RESULTS

A total of 679 TAPP IHRs in 466 patients were analyzed; 253 were unilateral, and 213 were bilateral. PF closure was performed using tacks in 36.7 %, suture in 24.3 %, and staples in 39.0 %. There was no difference in hernia recurrence (only 1 patient at 36 months). There were no statistical differences in QOL between 2 and 4 weeks and 6- to 24-month follow-up. When resolution of symptoms from preoperative levels was examined, there was no difference in the three groups at any time point (p > 0.05). After controlling for confounding variables on multivariate analysis, there was no difference in QOL by PF closure method at any time point (p > 0.05).

CONCLUSION

Tacked, sutured, and stapled techniques for peritoneal flap closure following TAPP have no significant differences in operative outcomes, postoperative quality of life, or resolution of symptoms.

Small bowel obstruction caused by self-anchoring suture used for peritoneal closure following robotic inguinal hernia repair

Laparoscopic inguinal herniorraphy is a commonly performed procedure given the reported decrease in pain and earlier return to activity when compared with the open approach. Moreover, robotic assistance offers the operating surgeon considerable ergonomic advantages, making it an attractive alternative to conventional laparoscopic herniorraphy. Robotic herniorraphy utilizes the transabdominal preperitoneal approach where following repair peritoneal closure is necessary to avoid mesh exposure to the viscera. Self-anchoring sutures are frequently used to this end given the ease of use and knotless application. We present an unusual case of post-operative small bowel obstruction following robotic inguinal hernia repair caused by the self-anchoring suture used for peritoneal closure. This patient presented 3 days post-procedure with symptoms and cross-sectional imaging indicative of small bowel obstruction with a clear transition point. Underwent laparoscopic lysis of a single adhesive band originating from the loose intraperitoneal end of the suture leading to resolution of symptoms.

Comparison of peritoneal closure techniques in laparoscopic transabdominal preperitoneal inguinal hernia repair: a prospective randomized study

PURPOSE

We aimed to compare tacker and suture techniques for peritoneal closure with respect to patient outcomes.

METHODS

A total of 64 patients were included in the study, 32 being in the tacker group and 32 in the suture group. All patients underwent laparoscopic TAPP inguinal hernia repair. Both groups were compared with respect to age, sex, duration of peritoneal closure and the operation, hernia type, the number of tackers used for mesh fixation, postoperative complication rate, visual analogue scale (VAS) scores on 1st, 7th, and 30th days, duration of follow-up, and recurrence rates.

RESULTS

Duration of peritoneal closure and the operation was significantly shorter in the tacker group compared to the suture group (p < 0.001, p = 0.008, respectively). Statistical analysis with the two-way analysis of variance method revealed that mesh fixation with one or two tackers did not influence postoperative pain. VAS 1 was significantly lower in patients with peritoneal closure with suture compared to the patients undergoing peritoneal closure with tacker (p = 0.027). VAS 7 and VAS 30 were lower for peritoneal closure with suture versus tacker, although the difference did not reach statistical significance (p = 0.064, p = 0.294, respectively). We observed no recurrence at an average of 21-month follow-up.

CONCLUSIONS

Tacker and suture appeared to have a comparable safety for peritoneal closure in laparoscopic TAPP inguinal hernia operation. It can be suggested that peritoneal closure with tacker increased short-term pain, independent of the number of tackers used for mesh fixation. Long-term pain was similar in both groups.